BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 2345
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AUTHOR: De La Torrre
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AMENDED: June 16, 2010
HEARING DATE: June 30, 2010
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CONSULTANT:
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Hansel/cjt
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SUBJECT
Health care coverage: federal health care reform
SUMMARY
Requires group and individual health care service plan
contracts and health insurance policies to provide
coverage, and not impose cost-sharing requirements, for
preventive services as specified by the Patient Protection
and Affordable Care Act (PPACA). Expresses the intent of
the Legislature to enact legislation to adopt as state law
various patient protection provisions of the PPACA and to
require DMHC and the Department of Insurance to post a link
on their respective Internet websites to the Internet
website of the federal Department of Health and Human
Services to provide information about affordable and
comprehensive health care coverage options.
CHANGES TO EXISTING LAW
Existing federal law:
Requires, under the PPACA (Public Law 111 - 148), health
plans and issuers, subject to the minimum interval
established by the US Secretary Health and Human Services,
to provide coverage, and not impose cost-sharing
Continued---
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requirements, for the following preventive services with
respect to plan years beginning on and after September 23,
2010
Evidence-based items or services that have in effect a
rating of `A' or `B' in the current recommendations of
the United States Preventive Services Task Force, with
specified exceptions.
Immunizations that have in effect a recommendation from
the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention with respect
to the individual involved; and
With respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided
for in the comprehensive guidelines supported by the
Health Resources and Services Administration.
With respect to women, such additional preventive care
and screenings not otherwise described above as provided
for in comprehensive guidelines supported by the Health
Resources and Services Administration for purposes of
this paragraph.
Provides under that PPACA that a plan or issuer may provide
coverage for services in addition to those recommended by
United States Preventive Services Task Force, and may deny
coverage for services that are not recommended by the Task
Force.
Contains, under the PPACA, numerous consumer and patient
protections, including those that:
Prohibit sponsors of group health plans, other than
self-insured plans, from establishing eligibility rules
for full-time employees that are based on the total
hourly or annual salary, or otherwise have the effect of
discriminating in favor of higher- wage employees.
Require health plans and insurers to implement processes
for appeals of coverage determinations and claims that
meet certain minimum requirements, including
providing notice and information to enrollees in a
culturally and linguistically appropriate manner;
allowing an enrollee to review their file, present
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evidence and testimony as part of the appeals process,
and receive continued coverage pending the outcome of the
appeals process; and providing an external review process
that meets certain minimum requirements, as specified.
Require health care service plans and health insurers to
comply with specified patient protections pertaining to
choice of provider, coverage of emergency conditions,
designation of pediatric specialists as primary care
providers, and access to ob/gyns, and establishment of
medical reimbursement data centers, as specified.
Requires, under the PPACA, the Secretary of the U.S.
Department of Health and Human Services, no later than July
1, 2010, to establish a mechanism, including an Internet
website, through which a resident of any state may identify
affordable health insurance coverage options in that state.
Existing state law:
Provides for the licensure and regulation of health care
service plans by the Department of Managed Health Care and
of health insurers by the Department of Insurance.
Requires DMHC-regulated health plans to provide all
medically necessary basic health care services, as defined.
Permits DMHC to define the scope of the required services
and to exempt plans from the requirement for good cause.
Requires every health plan or insurer that covers hospital,
medical, or surgical expenses, on a group basis, to provide
certain preventive health care benefits for children,
including immunizations.
This bill:
Requires group and individual health care service plan
contracts and health insurance policies issued, amended,
renewed, or delivered on or after September 23, 2010, to
provide coverage, and not impose cost-sharing requirements,
for preventive services as specified by the PPACA, subject
to the minimum interval established by the U.S. Secretary
of Health and Human Services pursuant to the PPACA.
Expresses the intent of the Legislature to enact
legislation to adopt as state law the patient protection
provisions of the PPACA dealing with eligibility of
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employees for group health coverage and prohibiting
discrimination in favor of higher-wage employees; appeals
of coverage determinations and claims; and patient
protections pertaining to choice of provider, coverage of
emergency conditions, designation of pediatric specialists
as primary care providers, and access to ob/gyns, and
provide for establishment of medical reimbursement data
centers, as specified.
Expresses intent to enact legislation to require DMHC and
the Department of Insurance to post a link on their
respective Internet websites to the Internet website of the
federal Department of Health and Human Services where
consumers may easily obtain information about affordable
and comprehensive health care coverage options under the
PPACA.
FISCAL IMPACT
The bill in its present amended form has not been analyzed
by a fiscal committee.
BACKGROUND AND DISCUSSION
According to the author, AB 2345 will require group or
individual health care service plans and insurers to
provide preventive health care services with no
cost-sharing, in accordance with the requirements of the
PPACA. The bill also expresses intent to adopt provisions
in the PPACA prohibiting group health plans from
discriminating in favor of highly compensated individuals
as to their eligibility to participate in the plan and
benefits included in the plan, requiring plans and insurers
to provide an internal claims and appeals process,
requiring plans and insurers to comply with several patient
protections in the PPACA, and to require DMHC and CDI to
post a link on their websites and to the website the U.S.
Department of Health and Human Services they will be
developing pursuant to the PPACA, to enable consumers to
easily obtain information about affordable and
comprehensive health care coverage options.
U.S. Preventive Services Task Force
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Included in the preventive services, this bill would
require health plans and insurers to cover effective
September 23, 2010, are those services that have an 'A' or
'B' rating in the most current recommendations of the U.S.
Preventive Services Task Force (USPSTF). The USPSTF, first
convened by the U.S. Public Health Service in 1984, and
since 1998 sponsored by the Agency for Healthcare Research
and Quality (AHRQ), is the leading independent panel of
private-sector experts in prevention and primary care. The
USPSTF conducts rigorous, impartial assessments of the
scientific evidence for the effectiveness of a broad range
of clinical preventive services, including screening,
counseling, and preventive medications. Its recommendations
are considered the "gold standard" for clinical preventive
services.
The USPSTF makes recommendations that certain services be
provided based on the risk and benefit of the service and
the level of evidence supporting the provision of the
service, and classifies services as follows:
Level A: Good scientific evidence suggests that the
benefits of the clinical service substantially outweighs
the potential risks. Clinicians should discuss the
service with eligible patients.
Level B: At least fair scientific evidence suggests that
the benefits of the clinical service outweighs the
potential risks. Clinicians should discuss the service
with eligible patients.
Level C: At least fair scientific evidence suggests that
there are benefits provided by the clinical service, but
the balance between benefits and risks are too close for
making general recommendations. Clinicians need not offer
it unless there are individual considerations.
Level D: At least fair scientific evidence suggests that
the risks of the clinical service outweighs potential
benefits. Clinicians should not routinely offer the
service to asymptomatic patients.
Level I: Scientific evidence is lacking, of poor
quality, or conflicting, such that the risk versus
benefit balance cannot be assessed. Clinicians should
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help patients understand the uncertainty surrounding the
clinical service.
Advisory Committee on Immunization Practices
Also included in the preventive services that health plans
and insurers would be required to cover are immunizations
that have in effect a recommendation from the Advisory
Committee on Immunization Practices (ACIP) of the Centers
for Disease Control and Prevention (CDC). The ACIP
consists of 15 experts in fields associated with
immunization, who have been selected by the Secretary of
the U. S. Department of Health and Human Services to
provide advice and guidance to the Secretary, the Assistant
Secretary for Health, and the Centers for Disease Control
and Prevention on the control of vaccine-preventable
diseases. In addition to the 15 voting members, ACIP
includes 8 ex officio members who represent other federal
agencies with responsibility for immunization programs in
the United States, and 26 non-voting representatives of
liaison organizations that bring related immunization
expertise.
The role of the ACIP is to provide advice that will lead to
a reduction in the incidence of vaccine-preventable
diseases in the United States, and an increase in the safe
use of vaccines and related biological products. The
committee develops written recommendations for the routine
administration of vaccines to children and adults in the
civilian population; recommendations include age for
vaccine administration, number of doses and dosing
interval, and precautions and contraindications. The ACIP
is the only entity in the federal government that makes
such recommendations.
HRSA Guidelines for preventive care and screenings for
infants, children and adolescents (Bright Futures
Guidelines)
Under the bill, health plans and insurers would be required
to cover evidence-informed preventive care and screenings
for infants, children, and adolescents, as provided for in
the comprehensive guidelines supported by the Health
Resources and Services Administration (HRSA) (referred to
as the Bright Futures Guidelines). These are comprehensive
guidelines addressing health promotion and disease
prevention in infancy, early childhood, middle childhood,
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and adolescence. Through collaboration between the HRSA
Maternal and Child Health Bureau and the National Center
for Education in Maternal and Child Health at Georgetown
University in Washington, D.C., the Bright Futures
Guidelines were developed by interdisciplinary panels of
experts from a wide variety of child health fields, such as
dental care, nutrition, nursing, and pediatrics.
Related bills
AB 1602 (Perez) among its provisions, requires, effective
September 23, 2010, health plans and health insurers to, at
minimum, provide coverage for and not impose any cost-
sharing requirements for preventive services as specified
by the PPACA. Scheduled to be heard in Senate Health
Committee on June 30, 2010.
AB 2787 (Monning) establishes the Office of the California
Health Ombudsman, to educate consumers on their health care
coverage rights and responsibilities, assist consumers with
enrollment in health care coverage, and resolve problems
with obtaining federal premium tax credits. Scheduled to
be heard in Senate Health Committee on June 30, 2010.
Arguments in opposition
The Association of California Life and Health Insurance
Companies has taken an oppose unless amended position.
ACLHIC states that at this time, it has not been officially
determined whether the PPACA requires health insurers to
cover out-of-network preventative services. ACLHIC
requests an amendment to clarify that if PPACA (through
future clarification or regulation) is interpreted to not
include coverage for out-of-network services, then
California law would also not require coverage for
out-of-network services.
PRIOR ACTIONS
(Prior version of bill)
Assembly Health: 13-0
Assembly Floor: 52-11
COMMENTS
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1. Existing patient protections may be stronger in some
cases. With regard to some of the patient protections of
the PPACA that the bill expresses intent to conform to, for
example, appeals processes for coverage determinations and
coverage of emergency conditions, existing California law
may be stronger than the PPACA. A suggested amendment
would be to delete subdivisions (a) - (c) of Section 3 of
the bill, which express the intent of the Legislature to
enact legislation to conform to the PPACA with regard to
eligibility for group coverage, choice of provider, appeals
processes, and coverage of emergency conditions, to allow
for a more complete analysis of how state and federal law
compare in these areas.
POSITIONS
Support: None received
Oppose: Association of California Life and Health Insurers
Companies (unless
Amended)
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